SOAP notes are a medical evaluation method that attempts to standardize the encounter between patient and physician. The goal of SOAP notes is to improve communication between all channels of patient care and organize that communication so it can be easily revisited later.
The components of a SOAP note
Subjective: Subjective observations such as symptoms as reported by a patient
Objective: Objective data such as measurable symptoms — e.g. fever, swelling, etc
Assessment: Diagnosis or possible diagnoses of a patient’s condition
Plan: Lays out provider’s plan for care such as tests, prescriptions, follow-up directions, etc.
NextGen Ambulatory allows users to save an entire SOAP note without losing the format, and they can reuse it for common findings using “Quick Note.” Users can also retain their preferences for procedures and exams using “Quick Saves.” If users navigate away from or finalize their SOAP note, it will remain in the same format when you return to it, speeding up the learning curve and streamlining template use.
Unlike many other EMRs, EpicCare Ambulatory EMR does not provide support for SOAP note. This is in part because of Epic’s proprietary data approach, which does not allow it to share data with non-Epic providers. Epic has its own encounter record of course, but it does not follow the standardized format of a SOAP note.